Brief Presentation on clinical examination of Respiratory System with Report of Normal case
references:
macleod's clinical examination 13th edition
hutchinson clinical methods
R Alagappan - Manual of Practical Medicine, 4th Edition
Cyanosis
Cyanosis refers to a bluish color of the skin and mucous membranes resulting from an increased quantity of reduced hemoglobin/deoxyhemoglobin or abnormal hemoglobin derivatives, in the small blood vessels of those areas.
DYSPNOEA IS DEFINED AS THE UNDUE AWARENESS OF UNPLEASANT BREATHING.WHEN THERE IS AMIS MATCH BETWEEN THE AFFERENT VENTILATORY SIGNALS AND THE EFFERENT RESPIRATORY SIGNALS IN THE BRAIN WE MAY GET AN UNIGNORABLE FEELING FOR NEED OF MORE AND MORE OXYGEN.
Brief Presentation on clinical examination of Respiratory System with Report of Normal case
references:
macleod's clinical examination 13th edition
hutchinson clinical methods
R Alagappan - Manual of Practical Medicine, 4th Edition
Cyanosis
Cyanosis refers to a bluish color of the skin and mucous membranes resulting from an increased quantity of reduced hemoglobin/deoxyhemoglobin or abnormal hemoglobin derivatives, in the small blood vessels of those areas.
DYSPNOEA IS DEFINED AS THE UNDUE AWARENESS OF UNPLEASANT BREATHING.WHEN THERE IS AMIS MATCH BETWEEN THE AFFERENT VENTILATORY SIGNALS AND THE EFFERENT RESPIRATORY SIGNALS IN THE BRAIN WE MAY GET AN UNIGNORABLE FEELING FOR NEED OF MORE AND MORE OXYGEN.
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BY DR. SURAJ R. DHANKIKAR.
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10. Respiratory Examination
Pectus carinatum Pectus excavatum
May prevent
complete expiration
of air from the lungs
and thus may restrict
air exchange
considerably.
Base lung capacity
is decreased
Chest wall
www.criticalcarepractitioner.co.uk
13. Respiratory Examination
• Percussion
– Illicit resonance
• Tactile vocal fremitis
– Compare both sides
– Map out abnormal area
www.criticalcarepractitioner.co.uk
14. Respiratory Examination
2nd phalanx over area of intercostal
space
Right middle finger strikes the 2nd
phalanx producing hammer effect
Entire movement comes from wrist
www.criticalcarepractitioner.co.uk
16. Respiratory Examination
Percussion
Impaired(dull)resonance obtained –
– Aerated lung tissue is separated from the chest wall
e.g. fluid, pleural thickening
– Lung tissue is airless e.g. consolidation, collapse,
fibrosis
“stony dullness”- pleural effusion
Hyperresonance - pneumothorax
www.criticalcarepractitioner.co.uk
17. Respiratory Examination
• Auscultation technique
– Diaphragm of stethoscope
– Mouth open
– Breathing deeply and fairly rapidly
– Systematic approach over several areas, comparing both sides
– Repeat asking patient to say “9,9,9” for vocal resonance
– Whispering pectoriloquy
• A whispering pectoriloquy is the increase in vocal resonance, to the extent
that when a patient whispers, his voice may be heard clearly with a
stethoscope on his chest over an area of lung consolidation.
www.criticalcarepractitioner.co.uk
19. Respiratory Examination
• Vesicular breath sounds
– Vibrations of the vocal cords caused by turbulent flow
through the larynx
– Transmitted along trachea, bronchi to chest wall
– Rustling quality
– Inspiration continuous with expiration
– Intensity increases during inspiration & fades rapidly
during first 1/3rd expiration
Jonathan Downham 2010
Basic Lung
Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html
http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm
20. Respiratory Examination
• Bronchial breathing
– “blowing” inspiratory & expiratory sounds
– Expiratory phase as long as inspiration
– Distinct pause between phases
– High-pitched e.g. consolidation
– Low-pitched e.g. fibrosis
www.criticalcarepractitioner.co.uk
Basic Lung
Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html
21. Respiratory Examination
Diminished breath sounds
Conduction limited by
– Airflow limitation
e.g. diffusely – asthma, emphysema
localised – tumour, collapse
– Something separating chest wall from lung
e.g. effusion, fibrosis
www.criticalcarepractitioner.co.uk
23. Respiratory Examination
• Wheeze
– Due to passage of air through narrowed bronchus e.g.
bronchospasm, mucosal oedema
– Musical quality
– High or low pitched
– Usually expiratory
– Expiration prolonged
www.criticalcarepractitioner.co.uk
24. Respiratory Examination
• Crepitations/crepitations
– Inspiratory noises, usually 2nd half
– Non-musical
– Due to explosive reopening of peripheral small airways
during inspiration which have become occluded during
expiration
www.criticalcarepractitioner.co.uk
26. Respiratory Examination
• Pleural Rub
– Creaking noise
– Movement of visceral pleura over parietal pleura
– Surfaces roughened by exudate
– 2 separate phases at end inspiration and early expiration
www.criticalcarepractitioner.co.uk
27. Respiratory Examination
• Vocal sounds
– Vocal resonance
– Increased when voice sounds are louder and more distinct
e.g. consolidation
– Reduced when transmission impeded e.g. effusion,
collapse
www.criticalcarepractitioner.co.uk
Basic Lung
Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html
28. Respiratory Examination
• Information from auscultation
– Type and amplitude of breath sounds
– Type of added sounds and their location
– Quality and amplitude of conducted sounds
www.criticalcarepractitioner.co.uk
30. Respiratory Examination
• Interpretation of findings
– Breath sounds locally reduced or absent over pleural effusion,
thickened pleura, collapsed area
– Breath sounds diffusely reduced in emphysema, asthma
– Rhonchi heard in asthma, COPD
– Crepitations may be widespread in COPD, LVF
– Crepitations localised in area of consolidation
– Pleural rub in pleurisy
www.criticalcarepractitioner.co.uk
Basic Lung Sounds:http://www.stethographics.com/main/physiology_ls_introduction.html
33. Respiratory Examination
• Summary of examination
– Note patients appearance and demeanour
– Observe rate and pattern
– Examine the hands
– Measure the BP
– Examine neck/JVP
– Inspect chest
– Trachea and apex beat
– Percuss front and back
– Auscultate front and back
www.criticalcarepractitioner.co.uk
34. Respiratory Examination
• Common Problems- Asthma.
– Baseline control
• Usual exercise tolerance
• Frequency of attacks
• Best Peak expiratory flow rate
• Usual precipitating factors
• Medication
• Usual response to therapy
• Previous hospital/ITU admissions
• Symptoms suggestive of poor baseline control
www.criticalcarepractitioner.co.uk
35. Respiratory Examination
• Common Problems – Asthma
– Drug History
• Do they have a nebuliser at home?
• Do they use a bronchodilator?
• Do they take theophylline or aminophylline?
(bronchodilators).
• Do they take steroids?
• Are they on medication which aggravates the
symptoms... Beta blockers, aspirin.
• Demonstrate inhaler technique.
www.criticalcarepractitioner.co.uk
36. Respiratory Examination
• Common Problems – Chronic Obstructive
Pulmonary Disease (COPD)
– Detailed history
• Time course
• Treatment given and effects
• Any hospital admissions in the last year
• Baseline function
• Chronically deteriorating exercise tolerance.
• Quantify normal amounts of sputum
www.criticalcarepractitioner.co.uk
37. Respiratory Examination
• Common Problems – Chronic Obstructive
Pulmonary Disease (COPD)
– Past Medical History
– Drug History
– Social History
– Review of systems.
www.criticalcarepractitioner.co.uk
38. Respiratory Examination
• Common Problems – Chest Infection
– History
• Cough
• Sputum Production
• Dyspnoea
• Wheeze
• Pleuritic chest pain
• Fever.
– Drug History.
www.criticalcarepractitioner.co.uk
Perfusion
Warm, cool, clammy?
Peripheral cyanosis
If cyanosed check for central cyanosis.
Tremor
Could be caused by nebuliser therapy
Flap
CO2 retention
Finger clubbing
Pulmonary hypertension, interstitial lung disease, lung cancer
Pulse
Central cyanosis
In patients with a normal Hb central cyanosis occurs with sats less than 90%
Neck veins
Maybe distended/check JVP
Lymphadenopathy
Feel for nodes in neck....will be covered later.
Trachea
Is it central
Crepitus
Surgical emphysema
Neck muscles
Use of accessory muscles
Pursed lips
Place two fingers on either side of the trachea and judge the distance between the fingers and the sternomastoid tendons.
Shape
Barrel chest, pectus carinatum (pigeon chest), pectus excavatum (funnel chest). ON NEXT SLIDE
Scars
Lesions
Resp rate
Resp depth
Abnormal respiratory movements
Pursed lips, accessory muscles, abdominal etc.
Asymmetry of movement
Previous tb causing upper lobe fibrosis, kyphoscoliosis
Primary objective is to assess symmetry
Place hands around lateral chest wall
Approximate thumbs in the midline NOT RESTING ON THE CHEST
Ask patient to take a deep breath
Observe displacement of thumbs from the midline.
Illicit resonance
Tactile vocal fremitis
Place the hand on the chest wall and ask the patient to make a resonant sound e.g. Say ‘ninety nine’
Increased over areas of consolidation
Decreased over areas of effusion or pneumothorax
VERY HARD TO JUDGE
Compare both sides
Map out abnormal area
Place your left hand on patients chest with fingers slightly separated
Press the middle finger of your left hand firmly against the chest, aligned with the underlying ribs over the area to be percussed.
Strike the centre of the middle phalanx of your left middle finger with the tip of your right middle finger, using a loose swinging movement of the wrist and not the forearm.
Remove the percussing finger
Wheeze
Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema causing continuous oscillation of opposing airway walls.
Musical quality
High or low pitched
Usually expiratory
Tend to be louder on expiration because airways normally dilate during inspiration and narrow on expiration
Expiration prolonged
Important to distinguish between wheeze and stridor which is heard on inspiration.
Crepitations
Inspiratory noises, usually 2nd half
Non-musical
Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration
Inhaler Technique Scoring
Prepares Device (e.g. Shakes inhaler) 1
Exhales fully 1
activates and inhales 1
holds breath for several seconds 1
Common Problems – Chronic Obstructive Pulmonary Disease (COPD)
Detailed history
In an acute exacerbation patients usually present following a cold with deterioration of dyspnoea in association with a productive cough and discoloured sputum.
Time course
Treatment given and effects
Any hospital admissions in the last year
Baseline function
How far can you walk?
Can you climb one flight of stairs easily?
Chronic bronchitis
History of cough, productive of sputum on most days, for 3 consecutive months, for at least 2 years.
Emphysema is a pathological diagnosis of dilatation and destruction of the lungs distal to the terminal bronchioles
Past Medical History
Previous admissions to hospital with acute exacerbations of COPD
Other smoking related illnesses (ischeamic heart disease, peripheral vascular disease, strokes, hypertension)
Other causes of lung disease (occupational exposure to dust, previous TB)
Asthma
Drug History
Bronchodilators
Home oxygen
Who initiated and on what evidence
How many hours per day is it being used
LTOT should be used for greater than 15 hours per day and its aim is to prevent cor pulmonale
Caused by increase in blood pressure in the pulmonary artery which leads to enlargement and subsequent failure of the right side of the heart.
Theophyliine.. Have levels been measured
Steroids
Inhaler technique
Social History
Consider all aspects of daily living
Need to stop smoking!!
Cough
Duration, productive or dry
Sputum Production
Quantity, colour, recent changes
Dyspnoea
Quantitative account of exercise tolerance at baseline and during the illness
Wheeze
Pleuritic chest pain
Common feature of pneumonia- be aware of pulmonary embolus
Fever.
If symptoms are prolonged , recurrent or associated with weight loss consider the possibility of an underlying malignancy especially if they are a smoker.